GW1-2021-03575_Well Construction - GW1_20210823

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: k
Robin Webb 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 2418 Q ft 105 ft' 40gpml
ft ft. 1
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
Greene Bros. Well & Pump, WT Inc FROM To DIAMETER THICKNESS MATERIAL
Company Name 0 f L 68 ft- 6 1/4', in Steel
2019-00390 16.INNER CASING ORTUBING(geothermal closed-loop)
2.Well Construction Permit#• FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State, Variance,etc) ft. ft- in.
3.Well Use(check well use): ft ft in.
17.SC
Water Supply Well: FROM REE TO DIAMETER' SLOTSIZE THICKNESS MATERIAL
Agricultural []MunicipaUPublic ft. ft. in.
Geothermal(Heating/Cooling Supply) X)Residential Water Supply(single) ft. ft. in.;
Industrial/Commercial DResidential Water Supply(shared) 18.GROUT
Irri ation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft- 20 ft- Bentonite
Monitoring ®Recovery fa ft.
Injection Well:
ft. ft.
Aquifer Recharge Groundwater Remediation
19.SAND/GRAVEL PACK if applicable)
Aquifer Storage and Recovery 13 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test ®Stormwater Drainage ft ft.
Experimental Technology ®Subsidence Control ft ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary)
Geothermal (Heating/Cooling Return Other(explain under#21 Remarks FROM TO DESCRIPTION color,hardness soil/rock type,grain size,etc.
0 ft- 68 ft- Clay �;
4.Date Well(s)Completed:7/09/21 Well ID# 68 ft 125 ft• Granite
5a.Well Location: ft ft.
Melissa Hutchins/Smart Builders ft ft.
Facility/Owner Name Facility ID#(if applicable) ft ft. ia��y
134 Chestnut Creek Rd Candler, NC 28715 ft ft. Y
Physical Address,City,and Zip ft ft. i R
Buncombe ��B L 545k639� 21.REMARKS
County Parcel Identification No.(PIN) ^�t�Cr aG�mo
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22. ertifiCati n:
35.459 N 82.737 w
07/09/21
6.Is(are)the well(s)oPermanent or Temporary Signature of Certified Well Contractor Date
By signing this form,I hereby certify th st the well(s)was(were)constructed in accordance
7.Is this a repair to an existing well: [3Yes or JBNo with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
If this is a repair,fill out known well construction information and explain the nature of the copy of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form.
23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page;to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:t SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 125 (ft,) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing:30 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:6 1/4 (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Undergrotind Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm)40 Method of test:2 hours 24c. For Water Supply&Iniecti In Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: HTH Amount: 22 tabs' completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources i Revised 2-22-2016
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